Provider Demographics
NPI:1457994980
Name:KIM, NICHOLAS S (DMD MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 ELSBREE ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-7212
Mailing Address - Country:US
Mailing Address - Phone:508-672-1069
Mailing Address - Fax:
Practice Address - Street 1:180 ELSBREE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-7212
Practice Address - Country:US
Practice Address - Phone:508-672-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1016683208600000X
MADN18597291223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery